Lead the way - Aetna

1 Lead the way FDR Medicare compliance guide July 2021 D (8/21) < >22 Inside I. What s an FDR?..3 to do the right compliance compliance to-do list ..8 V. FDR toolbox .. 14 Aetna refers to a subsidiary company of CVS Health , including but not limited to Aetna Health companies, Aetna Better Health companies, Aetna Life Insurance Company, Coventry Health and Life Insurance Company, Coventry Health Care companies, First Health Life & Health Insurance Company, SilverScript Insurance Company, and those joint venture entities in which a CVS Health subsidiary company has ownership interests and, under contract with the Centers for Medicare & Medicaid (CMS)

2 , offers or administers a Medicare Advantage (MA) plan, Medicare-Medicaid Plan (MMP), Dual-eligible Special Needs Plan (D-SNP), or a Medicare Prescription Drug Plan (PDP) ( Aetna Medicare business ). 3 < > I. What s an FDR? 44 > < An FDR is a Centers for Medicare & Medicaid (CMS) acronym that means first tier, downstream or related entity. Current CMS definitions1 A first tier entity is any party that enters a written arrangement, acceptable to CMS, with an MA organization or Part D plan sponsor or applicant.

3 These arrangements provide administrative or health care services to a Medicare-eligible individual under the MA program or Part D program. A downstream entity is any that enters a written arrangement, acceptable to CMS, with persons or entities. These persons or entities are involved with the MA benefit or Part D benefit. They are below the level of the arrangement and between the following: An MA organization or applicant A Part D plan sponsor or applicant A first tier entity These arrangements continue down to the level of the ultimate provider of both health and administrative services A related entity is any party that holds common ownership or control of an MA organization or Part D sponsor and.

4 Performs some of the MA organization or Plan D plan sponsor s management functions under contract or delegation Furnishes services to Medicare enrollees under an oral or written agreement Leases real property or sells materials to the MA organization or Part D plan sponsor (this occurs at a cost of more than $2,500 during a contract period) For more information, review the United States Code, 42 CFR and Health care providers are FDRs, too The compliance requirements in this guide apply to health care providers contracted with our Medicare network.

5 This includes physicians, hospitals and other provider types. Here are three reasons why: 1. According to MA regulations and CMS rules, providers who are contracted with us to provide health care services are first tier entities 2. Chapter 21 40 of the CMS Medicare Managed Care Manual lists health care services as an example of the types of functions a third party can perform. These functions are in relation to an MA organization s contract with CMS. This gives third parties first tier entity status. This means CMS compliance requirements apply to providers that provide health care services.

6 3. The flowchart in the same chapter and paragraph shows that entities providing health services and hospital groups are first tier entities. But if we contract with a hospital group and don t have a direct contract with the group s hospitals and providers, the hospitals and providers are downstream entities. What administrative services do FDRs provide? Some examples of administrative functions are: Claims processing Patient management Credentialing* Additional examples of FDRs include: Delegates Agents Broker organizations Pharmacies Other individuals, entities, vendors or suppliers contracted with us for administrative and/or health care services for our Medicare plans Medicare compliance program requirements also apply to entities we contract with for administrative services for our MA or Part D contracts.

7 You ll find stakeholder relationship flowcharts in chapter 21 40 of the CMS Medicare Managed Care Manual. *Under our Medicare Advantage (MA) contract with the Centers for Medicare & Medicaid Services (CMS), we re required to credential health care providers that participate in our Medicare network. We may contract with entities to perform these credentialing services on our behalf under a delegation agreement. CMS considers these delegated credentialing entities to be first tier entities. CMS identifies delegated credentialing entities as first tier entities in chapter 11, section of the 2013 CMS Medicare Managed Care Manual.

8 1T he Centers for Medicare & Medicaid Services (CMS). Medicare Managed Care Manual Chapter 21 Compliance Program Guidelines and Prescription Drug Benefit Manual Chapter 9 Compliance Program Guidelines. Centers for Medicare & Medicaid Services. January 11, 2013; pages 3, 5, and 7. Available at: July 7, 2021. > < II. Partnering to do the right thing Our partnership with you a first tier, downstream or related entity (FDR) is important to us. We need you to help fulfill our contracts with the Centers for Medicare & Medicaid Services (CMS).

9 And you can rely on us for the teamwork and support you need. Together, we ll provide quality administrative and health care services for Aetna Medicare members. Medicare plans We offer several types of Medicare plans: Medicare Advantage (MA) plans Medicare-Medicaid Plans (MMPs) Medicare Prescription Drug Plans (PDPs)Fulfilling compliance requirements As an Aetna FDR, you and providers that support the Medicare-Medicaid plan (MMP) must fulfill specific Medicare compliance We describe those requirements in this guide.

10 The following references in this guide apply to FDRs and MMP providers: The definitions for first tier entity, downstreamentity, and related entity on page 5 MA organizations, plans, programs, benefits,regulations and contracts Part D sponsors, plans, programs, benefitsand contractsPlus, you ll find helpful resources such as the links below in case you need to know more. Compliance resource How to use Electronic Code of Federal Regulations Search the United States Code by title. (The United States Code is also referred to as federal regulations.)